Readings and musings

Healthcare is an enormous part of our economy and arguably the part of our lives that is the most fundamentally important to determining our quality of life and happiness. But there is so much that is inefficient and can be improved. I wanted to briefly describe a few of the major problems, trends, and opportunity areas that excite me about the field.

Doctor payment models

Problem: Most doctors get paid on a fee for service model rather than an outcome model. This incentivizes more treatment and tests and does not punish readmissions/disease relapses. Measuring quality and outcomes in medicine is actually a very ill-defined and difficult challenge in and of itself. A medical problem could come from four areas (doctor's advice, patient genetics, patient choices, and external events), with the doctor only involved in one of them. Nonetheless, there must be something better we can do than the current state of affairs.

Somehow, it would be nice to align doctor incentives with patient health and allow more fluid access to care when people need it. Some of the current quality-tied compensation schemes are a step in that direction, but they are too narrowly defined and promote gaming the system. Projects like "medical homes" as well as some HMOs are making good progress in this direction. It would be nice if primary care doctors earned more so we had more of them (we are in desperate shortage now, which will only exacerbate with health care reform). They should also have more authority and pay when they keep their patients healthy as well as earn money for extra counseling around lifestyle issues (currently they don't earn for that).

Insurance company incentives

Insurance companies should incentivize health, not just pay for cures. While it is difficult, prevention is preferable to treatment. Not just HMOs, but all insurance companies should be paying our gym memberships and giving us rewards for using them (check in at the gym), subsidizing our expensive Whole Foods organic food purchases and multivitamins, giving us money for not smoking or drinking, etc. I learned that the reason a lot of this doesn't happen is that people switch individual insurance carriers frequently, and the benefits of positive lifestyle choices are only reaped over the long-term (by which point the insurance company might have been changed out).

Insurance companies that see patient claims as "losses" as opposed to normal operating costs seem backwards. I want companies that will incentivize health and be customer-service organizations, chosen by people for their helpfulness rather than simply as a lesser among evils.

Electronic medical records

There are many EMR systems out there already, and the government provides incentives to install them and "meaningfully use" them. However, from doctors I've spoken to, I've learned that most are still clunky and limited, aren't designed with the doctor and patient in mind (i.e., not human-centered), and most painfully of all, aren't interoperable. The vision of electronic records is that they would enable people to carry their data across providers and improve communication across organizations, but that hasn't yet been solved. Many people complain of doctors who don't communicate effectively, and part of it is behavior change and training, but another part is the tools available.

I'm wondering whether countries that offer "universal healthcare" are different in regards to the problems mentioned above. I know they are much worse in terms of doctor waiting times (which are expected to increase substantially in the US after health care reform) and have worse access to the top-of-the-line medical tech. But are their doctors more collaborative? What other problems do they have?

Real-time home monitoring technology

This is very closely related to what Paul Graham wrote about as "ongoing diagnosis." We only seek care when we have symptoms, as opposed to knowing much earlier if something is sub-optimal in our body and correcting it then and there. This is very aggressive and difficult from the technology standpoint, but that's why it also makes it really exciting for me. I've always dreamed of a machine that can scan my body quickly at home and tell me if I have broken bones or infections. Taking this one step further, it would "push" this info to me whenever my body state changes adversely instead of me having to repeatedly poll for it. This seems really cool and also really hard.

As far as EMR, other value prop is epidemiological and research value (i.e. being able to throw big data algos at all that data and finding trends, relationships, etc.).

Also, the doctor chihuahua is a good touch. :)

Reply

Max

9/28/2012 02:12:40 am

Totally agree. That is extremely exciting. I want one big system that has (potentially anonymized) DNA, healthcare data, and lifestyle data; we could learn so much.

Reply

Lucas

9/28/2012 05:23:53 am

I have a friend at Univ of Washington that works with a group that is aggregating data from the various cancer and HIV/AIDS research facilities in Seattle and throughout the country and is trying to do just that for this large-ish group (multiple thousands of people).

Thanks for this amazing post “Problems in medicine that interest me”. It was really fun to read the article. I think the doctor payment model, electronic medical records, and insurance company incentives are described by you in a very interesting way. You have really shared a very informative post about the medical issue.